PTManager Blog re fusions

[Guest guest]

Interesting article on the holding of payment to hospital pending review by

the RAC. (Initially affects the hospitals, and later the physicians... the

hospitals are supposed to control the physicians it seems). I was

interested in the ortho emphasis being spinal fusion but did not know if

those were typical codes or if it's easy to use other codes for fusions.

Maybe CMS is fearful that everyone and their dog does not need a fusion. I

would love to follow and see if this is a new direction or simply a better

documentation issue.

Steve Passmore PT, MS

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CMS Tightening the Screws on Unnecessary Procedures in Florida and

10 Other States -

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12/04/2011 @ 5:10PM |162 views

CMS Tightening the Screws on Unnecessary Procedures in Florida and 10 Other

States

After years of criticism that it has paid billions of dollars for

unnecessary procedures, the Centers for Medicare & Medicaid Services (CMS)

will soon ramp up efforts to rein in costs for unnecessary procedures. In

2012 CMS will perform an audit *before *paying for several big ticket

cardiology and orthopedic procedures in certain key states. The news has

provoked strong reactions from cardiologists and Wall Street.

In Florida <http://medicare.fcso.com/Billing_news/224921.asp>, in fact, 100%

of stent, ICD, and pacemaker implantation procedures will undergo review

before payment. Similar programs will take place in California, Michigan,

Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina,

and Missouri, but the precise percentage and mix of cases that will undergo

auditing has not yet been stated.

On November 15 the demonstration program was announced by

CMS<http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4176 & intNumPer

Page=10 & checkDate= & checkKey= & srchType=1 & numDays=3500 & srchOpt=0 & srchData= & key

wordType=All & chkNewsType=6 & intPage= & showAll= & pYear= & year= & desc= & cboOrder=dat

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:

The Recovery Audit Prepayment Review demonstration will allow Medicare

Recovery Auditors (RACs) to review claims before they are paid to ensure

that the provider complied with all Medicare payment rules. The RACs will

conduct prepayment reviews on certain types of claims that historically

result in high rates of improper payments. These reviews will focus on seven

states with high populations of fraud- and error-prone providers (FL, CA,

MI, TX, NY, LA, IL) and four states with high claims volumes of short

inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This

demonstration will also help lower the error rate by preventing improper

payments rather than the traditional “pay and chase” methods of looking for

improper payments after they have been made.

On November 21 Aranda, Jr, the president of the Florida chapter of the

American College of Cardiology (ACC), sent a letter to all ACC members in

Florida about the “very serious proposed changes… that you need to be aware

of immediately.” Arunda said that the Florida ACC “is fighting these onerous

regulations” and that staff at the national ACC headquarters planned to meet

with CMS officials.

Details of the CMS initiative only became widely known on Friday, when Wells

Fargo analyst Larry Biegelsen issued a report summarizing the initiative in

which he cited “reimbursement experts who have all indicated that this

initiative seems onerous for hospitals and will likely reduce procedure

volume because hospitals will begin making sure that every patient meets the

coverage criteria.”

Reaction to the report on Wall Street was immediate. According to an article

in Bloomberg

News<http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2011/12/02/bloomberg_a

rticlesLVLIFY1A1I4H.DTL>,

hospital and medical device stocks plunged after the report was issued on

Friday. Tenet Healthcare dropped 11% while Medtronic lost 6%.

Here is the position of the Florida ACC chapter, as stated by Jerold Saef,

the chair of the Third Party Reimbursement committee of the chapter, in the

letter to Florida cardiologists:

As of the first of the year, there will be 100% pre-payment audits on all

inpatient hospital stays relative to 15 DRG’s. 11 of these are cardiac and

4 are orthopedic. This means that all inpatient stays involving a listed

DRG will trigger a hold on any payment associated with Part A reimbursement.

Hospitals will not be paid for 100% of these admissions pending record

review. There will be a 30-60 day period during which the hospital records

will be reviewed for whether they support medical necessity for procedures

which occurred during the stay. The Part B

(physician) payment will proceed. If the determination is made that records

do not support necessity, then the entire hospital stay will be denied. The

physicians will receive a form letter which will be entitled a “Take-Back

Letter” requiring return of any funds paid in conjunction with the affected

hospitalization. This will affect all cardiologists and orthopedists

involved in the care – both invasive and noninvasive. This may include

outpatient reimbursement for follow-up care related to the hospitalization.

It’s not clear whether other specialists or primary care physicians will

also receive Take-Back Letters.

The premise under which this program is being initiated is that physicians

are not adequately documenting the justification for their procedures and

that as many as half the procedures performed may be unnecessary. This

estimate apparently arises from White House and Congressional concerns that

unnecessary procedures are being funded. They draw their conclusions from

Comprehensive Error Rate Testing (CERT).

In our discussions with FCSO, we are told this is an instruction from The

Center for Medicare and Medicaid Services (CMS), and that it is being

implemented nationally. We have confirmed via the National ACC that this is

the case in at least 10 other states. We are also told that if, after a

matter of months, it appears that the scrutiny being used is unnecessary,

there will be a shift in focus away from the initial DRG’s towards other,

different DRG’s.

The Chapter leadership is concerned that the Pre-Payment Audit Initiative is

being launched at all and, additionally, that it is being launched with

little more than 6 weeks warning. The FCACC and the Florida Orthopedic

Society both think that the previous Local Coverage Determinations (LCD)

that were formulated should have provided FCSO with the necessary tools to

fight over-utilization and fraud, and that no additional measures are

necessary at this time. It occurs when holidays are imminent and end of the

year finances are being addressed. We consider this unfair and

unprecedented. We are concerned that cardiology practices, already subject

to huge technical component cuts, loss of consult codes, increasing

certification overhead, costs of implementation of electronic medical record

systems and the Sustainable Growth Rate issue, will now be threatened by

unjustified “Take-Back” strategies.

Here is the list of DRGs

<http://medicare.fcso.com/Billing_news/224921.asp>which will be subject to

100% prepayment medical review in Florida:

- 226 — Cardiac defibrillator implant without (w/o) cardiac catheter

with (w/) major complications or comorbitities (MCC)

- 227 — Cardiac defibrillator implant w/o cardiac catheter w/o MCC

- 242 — Permanent cardiac pacemaker implant w/MCC

- 243 — Permanent cardiac pacemaker implant w/CC

- 244 — Permanent cardiac pacemaker implant w/CC or MCC

- 245 — Automatic implantable cardiac defibrillator (AICD) generator

procedures

- 247 — Percutaneous cardiovascular procedure w/drug eluding stent w/o

MCC

- 251 — Percutaneous cardiovascular procedure w/o coronary artery stent

w/o MCC

- 253 — Other vascular procedures w/CC

- 264 — Other circulatory system or procedures

- 287 — Circulatory disorders except acute myocardial infarction (AMI),

w/cardiac catheter w/o MCC

- 458 — Spinal fusion except cervical w/spinal curve, malign, or 9+

fusions w/o CC

- 460 — Spinal fusion except cervical w/o MCC

- 470 — Major joint replacement or reattachment of lower extremity w/o

MCC

- 490 — Back and neck procedures except spinal fusion w/CC/MCC or disc

device/neurostimulator

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